1. October 2–5, 2007  Lusaka, Zambia
STRATEGIES FOR BUILDING NATIONAL-SCALE LONGITUDINAL ELECTRONIC PATIENT MONITORING SYSTEMS FOR HIV TREATMENT AND CARE IN PEPFAR COUNTRIES
October 2–5, 2007  Lusaka, Zambia

2. SmartCare Implementation
Zambia Case Study
SmartCare Implementation
Dr. Mark Shields , CDC, Zambia
Derrick J. Muneene, CDC, Zambia 2

3. Population: 10.3M (2000 Census, CSO)
Over 1600 Health Facilities, some offer ART some offer PMTCT
Has 4 level health administrative structure

4. Presentation Outline The Preamble, Problem, Solution and Background
The Assessment (SWOT) of Health Information Systems in Zambia
The Design Methodology and Choice of Technology
The Development Organization and Process
The Implementation : Process, challenge and successes
The Current Next Steps

5. The Preamble, Problem, Solution and Background
SmartCare Scope :
More than just ART care – OPD longitudinal EHR system
EHR Developed based on Existing Zambia MoH Forms

6. Current SmartCare Modules
ART – Adult
ART – Paeds (NEW)
ANC-PMTCT
VCT/CT
Labour and Delivery
Postnatal (NEW)
Labs
Pharmacy
Various Reports

7. The Problem and Background

8. General service delivery and information challenges
Client confidentiality (especially with regards to HIV positive clients)
Unavailability of related health information (ART, TB etc) for continuity of care, to help improve patient care
Lack of system to facilitate patient follow-up for both mother and baby, and patients on ART
Data aggregation and reporting challenges
Etc

9. The Assessment (SWOT) of Health Information Systems in Zambia

10. Zambia H.I.S. SWOT Analysis
Assessment Item
Strengths
Weaknesses
Opportunities
Threats
Community
Card carrying practice : National, business and medical
Eagerness for Tech
Electronic devices not used in health settings
Absence of Standard Practices
Strong linkages between communities and local facilities
Potential for stigmatization for a card carrying system
Non compliance
Potential for distrust
Health facility
Medically Trained health workers
Good understanding of existing health paper system
Even coverage of population
No I.S./IT Training in educational institutions
No adequate I.S./I.T infrastructure
Availability of user friendly technologies to support non I.T. staff
Presence of initial donor support
Equipment misuse
Equipment theft
Lack of on going maintenance
Governance structure
Local Leadership support and good will
Presence of ICT qualified staff
Inadequate software development staff at top level
Inadequate ICT infrastructure
No Confidentiality protocols for health
Local Capacity building (for sustainability)
Staff migration

11. Zambia H.I.S. SWOT Analysis
Assessment Item
Strengths
Weaknesses
Opportunities
Threats
Community
Card carrying practice : National, business and medical
Eagerness for Tech
Electronic devices not used in health settings
Absence of Standard Practices
Strong linkages between communities and local facilities
Potential for stigmatization for a card carrying system
Non compliance
Potential for distrust
Health facility
Medically Trained health workers
Good understanding of existing health paper system
Even coverage of population
No I.S./IT Training in educational institutions
No adequate I.S./I.T infrastructure
Availability of user friendly technologies to support non I.T. staff
Presence of initial donor support
Equipment misuse
Equipment theft
Lack of on going maintenance
Governance structure
Local Leadership support and good will
Presence of ICT qualified staff
Inadequate software development staff at top level
Inadequate ICT infrastructure
No Confidentiality protocols for health
Local Capacity building (for sustainability)
Staff migration

12. Zambia H.I.S. SWOT Analysis
Assessment Item
Strengths
Weaknesses
Opportunities
Threats
Community
Card carrying practice : National, business and medical
Eagerness for Tech
Electronic devices not used in health settings
Absence of Standard Practices
Strong linkages between communities and local facilities
Potential for stigmatization for a card carrying system
Non compliance
Potential for distrust
Health facility
Medically Trained health workers
Good understanding of existing health paper system
Even coverage of population
No I.S./IT Training in educational institutions
No adequate I.S./I.T infrastructure
Availability of user friendly technologies to support non I.T. staff
Presence of initial donor support
Equipment misuse
Equipment theft
Lack of on going maintenance
Governance structure
Local Leadership support and good will
Presence of ICT qualified staff
Inadequate software development staff at top level
Inadequate ICT infrastructure
No Confidentiality protocols for health
Local Capacity building (for sustainability)
Staff migration

13. Zambia H.I.S. SWOT Analysis
Assessment Item
Strengths
Weaknesses
Opportunities
Threats
Community
Card carrying practice : National, business and medical
Eagerness for Tech
Electronic devices not used in health settings
Absence of Standard Practices
Strong linkages between communities and local facilities
Potential for stigmatization for a card carrying system
Non compliance
Potential for distrust
Health facility
Medically Trained health workers
Good understanding of existing health paper system
Even coverage of population
No I.S./IT Training in educational institutions
No adequate I.S./I.T infrastructure
Availability of user friendly technologies to support non I.T. staff
Presence of initial donor support
Equipment misuse
Equipment theft
Lack of on going maintenance
Governance structure
Local Leadership support and good will
Presence of ICT qualified staff
Inadequate software development staff at top level
Inadequate ICT infrastructure
No Confidentiality protocols for health
Local Capacity building (for sustainability)
Staff migration

14. The Design Methodology and Choice of Technology

15. The Development Team

17. But List is more than this …
M&E Staff : CDC, MoH
Training Staff : MoH, NG
Deployment support staff
etc

18. The Choice of Solutions
Data Transport
Data Entry
Data Storage
Date Synchronization

19. The Choice of Solutions
Data Transport
Data Entry
Data Storage
Date Synchronization

20. Continuity of Care : Existing Paper Methods

21. Continuity of Care : Computerized (SmartCare) Patient held tools

22. Data Transport
Enforces patient confidentiality and data security, especially for HIV positive mothers
Entire EMR is stored on card
ART, TB, PMTCT, VCT, etc

23. Data Transport
Enforces patient confidentiality and data security, especially for HIV positive mothers
System is password driven, with a role based security model (RBS)
Card data is compressed and encrypted
Card can not be read by a non CCPTS system – requires specialized card driver and code logic to read the data from the smart card

24. Data Transport Based on a distributed database model
The distributed databases are linked via a virtual network for data communication / synchronization, driven by the patient
‘the client serves AS the network’

25. A mother receiving s smart card for the first time

26. Data Transport Based on a distributed database model
The distributed databases are linked via a virtual network for data communication / synchronization, driven by the patient
Facility in District
Facility in District

27. Data Transport Based on a distributed database model
The distributed databases are linked via a virtual network for data communication / synchronization, driven by the patient
Facility in District
Facility in District

28. Facility by Facility synchronization
Data Transport
Based on a distributed database model
The distributed databases are linked via a virtual network for data communication / synchronization, driven by the patient
Facility in District
Facility in District
Facility by Facility synchronization

29. The Choice of Solutions
Data Transport
Data Entry
Data Storage
Date Synchronization

30. A Nurse using a touch screen for data entry

31. UI Objects, such as this soft keyboard, popup appropriately
Uses touch screens for ease of data capture
This reduces the computer literacy learning curve

32. 3. System Implementation… Cont iii. System Features
Uses touch screens for ease of data capture
This reduces the computer literacy learning curve

33. 3. System Implementation… Cont iii. System Features
Type ahead feature for text data, to speed data entry
Uses touch screens for ease of data capture
This reduces the computer literacy learning curve

35. The Choice of Solutions
Data Transport
Data Entry
Data Storage
Date Synchronization

36. SQL Server DB A Form of offsite backup C# Front end
Middle tier uses xml for
enumerations and
Data validations
SQL Server DB
(Free Express Edition)
Keyboard and mouse
are optional

37. 4. The Choice of Solutions
Data Transport
Data Entry
Data Storage
Date Synchronization, use and reporting

38. District in Prov District in Prov Facility in District
Country
National DB
De-duplication and De-identification algorithm
Prov in Country
Prov in Country
Provincial DB
De-duplication and De-identification algorithm
Province by Province synchronization
District in Prov
District in Prov
District DB
De-duplication and De-identification algorithm
District by District synchronization
Facility in District
Facility in District
Facility DB
Asymmetric Merge
Record Linkage/De-dup
Facility by Facility synchronization

39. The Development Organization and Process

40. The Development Process
The Zambia SmartCare Development, M&E, and Central Deployment Team
The Development Process
System Design and implementation Process
Government and NGO consensus
Formation of development teams
Concept formation
Identification of and collaboration with, existing systems:
ZEPRS, PTS, ARTIS, ARTServe, LABIS, HMIS
Consensus building and concept formation, Dec2003

41. 2. System Design and Implementation Process
Map of Initial District implimentation
Piloted in April, 2005
Consensus building and concept formation, 2002

42. 2. System Design and Implementation Process
Baseline survey, facility level data Analysis, use, flow of care and record keeping
2. System Design and Implementation Process
System Design and implementation Process
Map of Initial District implimentation
Piloted in April, 2005
Consensus building and concept formation, 2002

43. 2. System Design and Implementation Process
To date, there are more than 50 sites running the ART module of SmartCare capital with about 120,000 patients in the database
April, 2006, pilot district plans for district wide expansion, after which other district would follow
April, 2006, MoH approves CCPTS to be the national system for ART care
14 more Smart card facilities added in 2006
System expanded to include ART (CCPTS)
To date, there are 14 sites running the Delivery,ANC-PMTCT-VCT modules of SmartCare based in the initial pilot district, Kafue, with about 7,000 clients carrying smartcards, and stored in the database
System reviewed and fine tuned
Piloted in April, 2005
Consensus building and concept formation, 2002

44. 1 Day District Management Training session
3 Day Frontline Health worker staff training
3 Day Frontline Health worker staff Training
2 day Frontline Health worker staff Training

45. 2. System Design and Implementation Process
2007 Modules include integration with other systems and addition of new module: TB, OPD and under five
Addition of more modules and expansion of system …
To date, there are over 40 sites running the ART module of the SmartCare system nationwide, with about 90,000 patients in the database
April, 2006, pilot district plans for district wide expansion, after which other district would follow
April, 2006, MoH approves CCPTS to be the national system for ART care
12 more Smart card based facilities added in 2006
System expanded to include ART
(PTS TO CCPTS)
To date, there are 12 sites running the ANC-PMTCT-VCT modules of SmartCare based in the pilot district, Kafue, with about 5,000 patients carrying smartcards, and stored in the database
System reviewed and fine tuned
Piloted in April, 2005
Consensus building and concept formation, 2002

46. 2007 Work Effort includes: SmartCare and Careware integration

47. The Implementation

48. 2006 SmartCare Coverage

49. 2006 SmartCare Coverage

50. 6. Lessons Learned

51. Lessons learned
Smart card adherence has been estimated to be about 98%. This shows that patients will remember to bring smart cards when seeking health care
card loss rate is estimated at < 0.4% / person-year
Good community awareness led to patient acceptance
Inclusion of smart card lessons during group education increases patient confidence and smart card adherence

53. Lessoned learned
Using touch screens instead of keyboards and mouse reduces computer training time. Health workers were able to work alone with minimum supervision.
Interactive software development increases user ownership
Presence of local development team increases software processes

54. Some Challenges Harmonization with legacy system (paper based)
Adherence to international standards
Printing capacity in low power locations
Availing decision support to services that function out doors, like the TB corner
Ongoing hardware maintenance
By facility staff

55. Current SmartCare Activities
Training
Provincial ToT performed on existing models
Provincial/District Scale up underway
SmartCare and other systems integration (e.g. Careware)
Addition of modules
Light weight OPD
TB module
SmartCare use in research activities: Migrant Health workers study
E-Learning centre at MoH for continuous education
Mapping functionality

56. Example interface for querying the data to generate a map report

57. Example map report interface showing: District map type, color shading, manual classification (user enters break values).

58. Example of: District map type, queried to southern province, color shading, manual classification (user enters break points), and labeling enabled.

59. Example of: Health facility catchment map type, drawing a background layer (health facility points), gray shading, and equal interval classification.
Data in this mapping example are fictional.

60. 5. Next steps
Rollout
Integration with other systems

61. CCPTS Smartcard based System
Conclusion
System has capacity to guide health worker in service delivery and protocol adherence by using decision support tools
CCPTS Smartcard based System
Produces flexible HMIS data, based on raw data
Enables patient information to be available to other services, there by introducing continuity of care, and a continuous medical record

62. CCPTS Smartcard based System
System has capacity to guide health worker in service delivery and protocol adherence by using decision support tools
CCPTS Smartcard based System
Produces flexible HMIS data, based on raw data
Thank You!!!
Enables patient information to be available to other services, there by introducing continuity of care, and a continuous medical record